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Stanford Medicine 25 Blog

Medical Errors and Adverse Events from a Missed or Inadequate Physical Exam

January 13, 2016

In the last 20 years the knowledge base for a physician has grown exponentially. Meanwhile technological advances, combined with a growing healthcare system and greater demands on the physician have left the need to find more ways to overcome these challenges. The physical exam, once regarded in the medical profession and the litmus test to the quality of a doctor and vital to the care of patients has been slowly forgotten. Now doctors, who once spent the majority of their time at their patient’s bedside and nearby collaborating with others are sitting at a computer feeding the hungry monster we call the electronic health record: often times ordering test such as CT scans, MRI’s and other advanced and often expensive diagnostics tests with hope that diagnoses will be not be missed, nor will the need for the physical exam. But this comes at a price. A recent published article in The American Journal of Medicine from author’s at Stanford School of Medicine, including the lead author, ourDr. Abraham Verghese interviewed physicians and documented where the physical exam was missed or not conducted. They reported 208 clinical vignettes and found that 63% of these events occurred because the exam was not conducted, 14% reported that correct exam finding was elicited but misinterpreted and 11% were from a relevant exam sign missed or not sought out. They also found that the physical examination inadequacy included missed or delayed diagnosis in 76% of cases, incorrect diagnosis in 27%, unnecessary treatment in 18%, no or delayed treatment in 42%, unnecessary diagnostic cost in 25%, unnecessary exposure to radiation or contrast in 17%, and complications caused by treatments in 4%.

Most errors in the physical examination that lead to consequences are related to not performing an examination.

These vignettes were recorded from both residents and practicing physicians and highlight issues surround the medicine where it was noted in the paper that at much as 100,000 deaths occur in the United States that are attributable to medial error. While it’s not been studied how much improving physical exam skills and providing a culture doctors have more time to be with their patients, we believe this is crucial. The Stanford 25 is leading the charge in this area and support from large entities such as the Institute of Medicine whose recent mention of the importance of the bedside physical exam in their report is leading to a change in our culture that will make our doctors better.

Read the full article to learn more. Below is additional information from this publication including a full list of the physical exam findings that were missed.

Sister Mary Joseph

Figure showing time to identifying discovery of missed exam.

Supplementary Table – Complete List of Items Missed as Reported in Returned Questionnaires

Missed skin finding of subcutaneous emphysema

Missed pulse absence in ischemic foot

Missed pregnancy with twins before hysterectomy

Missed hip fracture labeled as right lower quadrant pain

Missed Bell’s palsy

Missed liver mass, abdominal mass in cholangiocarcinoma

Missed funduscopic finding of cupping

Missed strangulated groin hernia in small bowel obstruction

Missed incarcerated femoral hernia

Missed crackles in a patient with pulmonary edema

Missed finger pressure necrosis on microvascular free flap

Missed peritoneal signs and free air on plain film

Missed peritonitis in patient with gangrenous perforated gall bladder

Missed adenopathy and therefore chronic lymphocytic leukemia

Missed thyromegaly in patient with tachycardia

Missed strangulated hernia

Missed fungating breast mass

Missed pelvic examination and therefore missed tubo-ovarian abscess

Missed pregnancy by missed gynecologic examination in patient with seizures

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